Analysis Sheet 1a

Demographic and Socioeconomic Characteristics of Study Population

Gender: _________

Age: _________

1. From how long you are suffering from Diabetes?

a) Less than 3 years b) Less than 5 years
c) Less than 10 years d) More than 10 years
2. What is the highest level of education you have completed?
a) Primary education b) secondary school education
c) High secondary school d) graduation e) post graduate
3. From which class do you belong?
a) Upper class b) Upper Middle class
c) Lower middle class d) Lower class
4. Is your Family giving full support in regard of diabetic treatment?
a) Non Supportive b) Less supportive
c) Supportive d) Careless
Analysis Sheet 2

Social factors affecting the health related quality of life of a

diabetic patient

Not
Slightly Affectin Extremely
Sr. Affectin
Question From Study Population affecting g affecting
No g
2 3 4
1

1 Punctuality Level of Doctors

2 Attitude of health care provider

3 Attitude of family towards disease

4 Quantity of internally available medicine

The restrictions your diabetes places

5
on your family and friends

6 Provision of Free diagnostic services

Satisfaction level about pharmacist behavior or

7
consultation.
Analysis Sheet 3

Psychological factors affecting the health related quality of life

of a diabetic patient

Sr. Sometime
Questions From Study Population yes No
No s

1 Are you feeling your disease is burden?

Food restrictions required to

control your diabetes affecting
3
you?

You feel ill while doing your daily

4
routine activities?

you are not enjoying life you were

5
enjoying it before
Not being able to do what you
6
want?
Do you feel embarrassment in telling
7
other people about disease?
Testing your sugar (glucose)
8
levels
9 having your schedule center
around diabetes
11 Feeling blue or depressed
 Analysis Sheet 4

Economic factors affecting the health related quality of life of a

diabetic patient

Sr.
Questions From Study Population Yes No
No
1 Your cost of treatment is high?
worries about money matters is reason of
2 not proper treatment ?

3 After diagnosis of disease your budget is disturb?

Other illnesses besides diabetes causing

4
problem for treatment?

You are not taking proper medicine because of

5
financial issues.?

Overall rating

1. Please place X on the line below that indicates your rating of your overall quality of
life.

1____2_____3____4____

2. Please place an X on the line below to show how severe you think your diabetes is.

1____2____3____4___